Nursing homes face deadline to provide trauma-informed care

April 15, 2019


Providing care to elderly residents who have suffered past trauma will require an organizational cultural shift for skilled nursing facilities preparing to comply with new federal rules, experts said during a CHA webinar.

Beginning in November, the Centers for Medicare and Medicaid Services will require nursing homes to provide services that are "culturally competent and trauma-informed." This marks the third phase of requirements of participation for nursing homes that CMS has rolled out since fall 2016.


Jill Schumann, president and chief executive of LeadingAge Maryland and one of the webinar presenters, said the organizational goal of trauma-informed care is to develop a deep awareness of ways to provide a helpful and healing environment for people who have suffered trauma.

During the Feb. 21 webinar titled "Trauma-Informed Care — Practical Implications," Schumann related how the staff at one long-term care facility was able to determine why a patient with dementia became aggressive and combative at the same time each night.

By having someone sit in the man's room during the time leading up to the outbursts, the staff realized that the disruptions occurred during shift changes. The man's room faced the parking lot and vehicle headlights flashed into his room.

The man had a history of combat stress "and was responding ... as if something very scary was going on," Schumann said. Staff installed blackout shades on his windows and the behavior ceased.

Individual trauma results from someone experiencing an event, series of events, or circumstances that are physically or emotionally harmful or life-threatening and have lasting adverse effects on that person's functioning and well-being, said Karen Key, president and chief executive of Heller Key Management Consulting in Washington, D.C., who also presented during the webinar.

Trauma covers a wider range of experiences than those that might be termed "top of mind," such as the trauma associated with wartime combat or domestic violence, Key said.

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Other sources of trauma can include being the victim of hate speech, being in a car accident or living with a family member who suffers from mental illness, she said.

Some of the earliest sources of research into the effects of trauma included that suffered by soldiers at war, and the links between childhood abuse, neglect, maltreatment and the risk of poor health in adults.

"The work of becoming trauma-informed in our field is at its earliest stages," Key said. "This is not necessarily about treatment directly of the trauma history, but it's about creating a setting in which people who are trauma survivors feel safe and can move toward well-being."


Key said caregivers for older adults should learn to view behavior through "the trauma lens." For instance, an older adult who will not allow a certified nurse assistant to help with personal care may have had a past experience of physical or sexual abuse that would explain the behavior.

An older resident who refuses to cooperate with medical treatment may have suffered a medical trauma, such as a botched surgery or treatment that caused great pain, she said.

"So if you think about the possibility that a past trauma might be a factor, that is just another piece of the puzzle," Key said. "It's another possible explanation for what we're not sure we understand in an older person's behavior."

Schumann said there are four basics that comprise a trauma-informed approach to care. They are: the realization that there are people affected by trauma throughout an organization, including staff; the recognition that everyone in the organization needs to understand trauma-informed care; undertaking an organizational response to ensure staff knows the language and behaviors that signal past trauma and have tools to address it; and making active efforts to recognize and avoid anything that might re-traumatize people.

The goal of trauma-informed care, she said, is to create an organization that maintains an "intentional and ever-deepening awareness" of the ways an environment and its people "can be healing and helpful" for people with trauma.



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